For OMC Staff Use Only
Authorization for Chart/MR #:
Release of Health Information Released by:
Date released:
Please note: If any section is incomplete, this form becomes invalid.
Name
Address
Patient:
City State Zip
Date of Birth SSN Phone
I authorize the following facility/provider to release my health information upon this request:
Health Information Name Specific office
Released From:
Address Phone/Fax
City State Zip
I authorize my health information to be disclosed to:
Health Information Name Attn
Disclosed To:
Address Phone/Fax
City State Zip
Please note: If dates are not provided, only the last visit will be disclosed.
Copies of clinic notes from (date) to (date)
Copies of hospital records from (date) to (date)
Psychology/Psychiatry records from (date) to (date)
Health Information Laboratory reports from (date) to (date)
to be Disclosed: Radiology Reports from (date) to (date)
X-ray films from (date) to (date)
HIV/AIDS Testing/Treatment from (date) to (date)
Alcohol/Drug Abuse Evaluation/Treatment from (date) to (date)
Other (Please specify)
Personal Disability Out of town move
Reason for
Disclosure: Consult/Second Opinion Insurance Application Insurance change
Treatment Legal Other
I understand that I have the right to revoke my authorization at any time. I understand that if I revoke this
authorization, that I must do so in writing and present my written revocation to the Health Information
Department. I understand that the revocation will not apply to information that has already been released in
response to this authorization. I understand that the revocation will not apply to my insurance company when the
Revocation:
law provides my insurer with the right to contest a claim under my policy. I understand that this authorization will
be in effect for 12 months from the date signed unless revoked by me in writing and is only valid for the
information specified above. If additional information is requested, a new authorization will be required. OMC will
only release information that is dated up to the date signed.
I understand that authorizing the release of this information is voluntary. I understand that I may inspect or be
provided a copy of the information to be used or disclosed, as provided in CRF 164.524. I understand that any
release of information carries with it the potential for an unauthorized redisclosure and the information may not
be protected by federal confidentiality rules. If I have questions about disclosures of my health information, I may
contact Olmsted Medical Center’s Privacy Officer. I understand that Olmsted Medical Center will not condition
treatment, payment, enrollment, or eligibility for benefits on whether I sign the authorization.
Please allow up to 30 days to process this release.
Authorization:
______________________________________________________ _____________________________
Patient/Parent/Guardian Signature (ages 18 and older must sign) Date
_____________________________________________________________
Relationship to Patient/Authority (please submit documentation of authority)
Olmsted Medical Center Locations
Rochester Southeast Hospital Byron Plainview Spring Valley
210 Ninth Street SE 1650 Fourth Street SE Chatfield Preston Stewartville
Rochester, MN 55904 Rochester, MN 55904 Pine Island Rochester Northwest Wanamingo
507.288.3443 507.529.6600 St. Charles
Translated Versions: Consent – Authorization for Release of Information: 1032407 – English 2080403 – Spanish 2080503 - Somali
1032407 rev1110